AHA: Lowering BP No Help in Acute Stroke

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Use of antihypertensive drugs to lower systolic blood pressure by close to 13% as part of acute treatment of ischemic stroke did not reduce early mortality or disability compared with patients who did not received antihypertensive therapy.

Note that stroke patients treated with thrombolysis were excluded from the study.

DALLAS -- Use of antihypertensive drugs to lower systolic blood pressure by close to 13% as part of acute treatment of ischemic stroke did not reduce early mortality or disability compared with patients who did not receive antihypertensive therapy, researchers said.

He reported the findings from China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) at the American Heart Association scientific sessions here and the results were simultaneously published online by the Journal of the American Medical Association.

The lack of benefit occurred despite the fact that antihypertensive therapy achieved a rapid and significant reduction in systolic blood pressure "from 166.7 mmHg to 144.7 mmHg (−12.7%) within 24 hours, versus 165.6 mm Hg to 152.9 mm Hg (−7.2%) in the control group (P<0.001)," he said.

Moreover, current American Stroke Association guidelines recommend use of antihypertensive therapy to lower systolic pressure in patients who are undergoing thrombolysis -- a population that was excluded from this study -- or patients with "markedly higher blood pressure" -- 220 mmHg/120 mmHg a group that was also excluded from the CATIS trial.

The presenter He noted that in large artery disease, the concern is more often to "raise blood pressure in order to increase reperfusion to the infarct area."

As result, Sacco, who is a former president of the AHA, said the CATIS results didn't produce guideline-changing evidence.

Despite the null findings, Sacco said there was a number of take-home messages for stroke treatment:

"First, if blood pressure is not markedly elevated, this provides reassurance that we don't need to aggressively treat it in in the acute setting."

"The data at 3 months hint of a possible benefit in recurrent stroke, although not significant (P =0.07).

Larry Goldstein, MD, of Duke University agreed there "was a suggestion that those randomized after 24-hours may have had somewhat better outcomes after 3-months compared to those randomized within 24-hours of symptom onset."

Goldstein, who commented on the study in an email to MedPage Today, noted that the results suggest, "it would seem safe to do so starting 24-hours after symptom onset, but the decision of when to start these medications needs to be individualized."

The study recruited 4,071 ischemic stroke patients who had baseline systolic pressure of more than 140 mm Hg, but less than 220 mmHg, and evenly randomized them to treatment with enalapril (first line), calcium channel blockers (second line), or diuretics (third line) with a goal of reducing systolic pressure by 10% to 25% within 24 hours of randomization.

The authors concluded, "our findings most likely are applicable for the majority of patients, who currently do not receive intravenous thrombolytic therapy."

This study was supported by Tulane University and Collins C. Diboll Private Foundation, both in New Orleans; Soochow University, a Project of the Priority Academic Program Development of Jiangsu Higher Education Institutions, China; and the National Natural Science Foundation of China (grant 81320108026). The Changzhou Pharmaceutical Factory provided the study drug (enalapril) for this trial.

He reported no financial conflicts of interest.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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